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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# <br /> SERVICE REQUEST# <br /> Q <br /> OWNER/OPERATOR 1(^ �}�(^1�- L 1 Y \ CHECK if BILLING ADDRESS <br /> IAXuTYNAME / ('' , (,� <br /> C-DiCtc�Ch�'��CS <br /> SITE ADDRESS <br /> L- <br /> Stmt Number Direttlwr `(rL rY�P(] <br /> Stmt Name city <br /> Zi C� <br /> HOME or MAILING ADDRESS (H Different from Site Address) <br /> Street Numlrer N <br /> CITY STATE Zip <br /> PHONE#1 EXT. APILAND USE ILICATION# <br /> ot-(- zs� <br /> PHOMi#2 �• BOS DISTRICT <br /> I ) LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK H BILLING ADDRES <br /> BUSINESS NAME <br /> �tl'f Ct/ rv1 PRDNE# Ex,. <br /> HOME or MAILING AoDRESIR FAX# <br /> CITY STATE ZIP qszzo <br /> BILLING ACKNOWLEDG MENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that i have prepared this application and that the work to perfo ed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FED L t <br /> APPLICANT'SSIGNATU , DATE: J/' Z3' O 1 <br /> PROPERTY/BUSINEss OwN OPERATOR/ R ❑ R AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PAR 7Y proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. .r <br /> TYPE OF SERVICE REQUESTED:— S-01 L- .S<-t-tT !L r T� — I Eiv <br /> COMMENTS: f� <br /> RE 'ED NOV 2 3 2004/�� <br /> mai ��yOo4 uIN cOu <br /> E ONMENTAL <br /> SAN J OUIN COUD�GME - -�- C <br /> ENVIRONMENTAL <br /> ACCEPTED BY: rx.�C C��/ EMP EE 3 y/ DATE: (� G <br /> ASSIGNED TO: /•.tr=L tAAq EMPLOYEE#: �3 DATE: <br /> Date Service Completed (H already completed): SERVICE CODE: SZ PIE: <br /> 2-6 <br /> Fee Amount: 3n Amount Paid / 0-0 /,� Payment Date y j .0 . e2 /D l� <br /> Payment Type �;' Invoice# Check# a Received By: <br /> EHD 48-02-025 <br /> EVISED 11/17/2003 SR FORM(Golden Rod) <br />